Provider Demographics
NPI:1952924920
Name:JACKSON, LETTA M (RN)
Entity Type:Individual
Prefix:
First Name:LETTA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15250 SIESTA KEY WAY APT 243
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-5553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 FOREST GLEN RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-1460
Practice Address - Country:US
Practice Address - Phone:301-754-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-25
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR236785163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine